Your Name or Company Name
Your City, TX Zip
Your Phone Number &(111 ) xxx-xxxx Fax: (xxx) xxx-xxxx
Xxx, TX 7xxxx
City, State, Zip Code
Request for Change of Address or Boxholder
Information Needed for Service of Legal Process
Please furnish the new address or name and street address (if a boxholder) for the following:
The following information is provided in accordance with 39 CFR 265.6(d)(5)(ii). There is no fee for providing boxholder information. The fee for providing change of address information is waived in accordance with 39 CFR
265.6(d)(1) and (2) and corresponding Administrative Support Manual 352.44a and b.
THE SUBMISSION OF FALSE INFORMATION TO OBTAIN AND USE CHANGE OF ADDRESS INFORMATION OR BOXHOLDER INFORMATION FOR ANY PURPOSE OTHER THAN THE SERVICE OF LEGAL PROCESS IN CONNECTION WITH ACTUAL OR PROSPECTIVE LITIGATION COULD RESULT IN CRIMINAL PENALTIES INCLUDING A FINE OF UP TO $10,000 OR IMPRISONMENT OR (2) TO AVOID PAYMENT OF THE FEE FOR CHANGE OF ADDRESS INFORMATION OF NOT MORE THAN 5 YEARS, OR BOTH (TITLE 18 U.S.C. SECTION 1001).
I certify that the above information is true and that the address information is needed and will be used solely for
Service of legal process in connection with actual prospective litigation.
_____________________________ Your address again here
Signature City, TX 7xxxx
Print your name here
FOR POST OFFICE USE ONLY
NEW ADDRESS or BOX HOLDER’S POSTMARK
___ Not known at address given.
___ Moved, left no forwarding address.
___ No such address. NAME and STREET ADDRESS
___ No change of address order on file.